Nurses speak in the hallway at the Balfour M. Mount Palliative Care Unit of the Montreal General Hospital in Montreal on Monday, February 10, 2014.

Photograph by: Dario Ayala
, Montreal Gazette

TORONTO - Doctors need to move beyond the "yes or no" debate about physician-assisted death and begin preparing policies and guidelines in the event the act is legalized in Canada, a group of palliative-care specialists argues.

In a commentary in Monday's Canadian Medical Association Journal, the doctors say the debate about assisted suicide has become mired in for-and-against arguments.

"And we felt this focus of the debate was rapidly becoming obsolete," co-author Dr. James Downar said in an interview.

"It seems clear that physician-assisted death will become legal in Canada in the very near future by one means or another," said Downar, a Toronto doctor who cares for the terminally ill. "And we felt that Canadians would be better served if the debate were to shift to more practical considerations about what that might look like."

He said doctor-assisted suicide could become legal if the Supreme Court of Canada, which will review the existing law in October, throws out the current statute that bans someone from seeking medical aid to end his or her life.

The case stems from a 2012 B.C. Supreme Court ruling that found the ban on assisted suicide was unconstitutional. Right-to-die advocates, aided by the British Columbia Civil Liberties Association, took the issue to Canada's highest court after the B.C. Court of Appeal overturned the earlier provincial court ruling last October.

Quebec also had been looking at legalizing doctor-assisted death with Bill 52, which died on the order paper when the provincial election was called.

Assisted suicide is legal in several European countries, among them Belgium and the Netherlands, and five U.S. states, including Washington and Oregon.

If the Supreme Court of Canada were to strike down the existing law, the onus would be on physicians to deal with any terminally ill patients who want help to end their lives due to physical and/or psychological suffering, said Downar.

"And all of a sudden, we are going to have a very short amount of time to come up with policies and practices in Canada to make sure there is at least some structure or guidelines ... and oversight to make sure that safeguards are in place."

Those policies would include ways of protecting vulnerable people from physician-aided death against their will, shielding doctors from any legal fallout and supporting palliative care.

But Dr. Louis Hugo Francescutti, president of the Canadian Medical Association (CMA), said Downar and his three co-authors have put "the cart well before the horse" in concentrating on physician-assisted death.

Instead, the focus should be on "addressing the dire need for improved access to palliative-care services ... and Canada's lack of a national pain strategy," Francescutti said Monday in a statement.

Delegates to the CMA's annual meeting last August voted against reopening the question of doctor-assisted suicide, arguing that physicians need to know more about how Canadians view the full spectrum of end-of-life care before changing the CMA's current position.

The organization, which represents about 78,000 doctors across the country, does not support euthanasia or assisted suicide.

Euthanasia is defined as the act of killing someone who is sick or injured to prevent more suffering, while physician-assisted death involves a doctor helping a person commit suicide by providing a prescription or information about a lethal dose of drugs.

"While physicians may indeed need to be prepared for the challenges of physician-assisted death," Francescutti said, "we are hearing from Canadians that there is an even greater need for our society to ensure we provide high-quality palliative care to everyone who would need it."

Downar said doctor-aided death should by no means be viewed as an alternative to palliative care.

"I think while we are pursuing the legalization of physician-assisted death in Canada, we should be equally strong in pursuing and continuing to advocate for expansion and growth of palliative care services across Canada."

Most patients' needs are met by quality end-of-life care, including effective pain control, although a small percentage of patients do experience physical suffering despite doctors' best efforts, he said.

"And then there is also the question of existential or spiritual or psychological distress," said Downar, adding that it can be difficult for people to contend with the idea they may lose control of their bodily functions as their illness progresses and ultimately control over the circumstances of their death.

"And that to them is an insult and an injury to their dignity that is, I think, as bad or worse than any physical symptom they could suffer."

In the end, he said, it comes down to patient choice.

"Palliative care is about choice. Palliative care is about choosing comfort and quality of life and dignity. And physician-assisted death is, in my opinion, about choosing the same thing."

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Note to readers: This is a corrected story. A previous version did not fully detail what preceded the SCOC hearing this October.